From the Editor

Have you made best use of the Bakri balloon in PPH?

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Reach for the balloon often and, for greatest benefit, apply it early in the postpartum hemorrhage treatment algorithm




Obstetricians know that postpartum hemorrhage (PPH) must be treated decisively and swiftly.1 To review:

Active management of the third stage after vaginal delivery, with a uterotonic such as oxytocin, helps to reduce the frequency of PPH2; in a recent randomized trial involving vaginal delivery, the rate of PPH was 10% in women who received postpartum oxytocin and 17% in those who did not (P<.001).3

When hemorrhage occurs despite oxytocin, having been given postpartum, the standard treatment algorithm (see the TABLE) calls for:

  • uterine massage
  • additional uterotonics
  • identification and repair of vaginal and cervical lacerations
  • removal of any retained products of conception.

Sequential interventions for managing postpartum hemorrhage

This sequence of steps applies 1) after vaginal delivery (including the left hand-side interventions) and 2) after cesarean delivery, with the abdominal incision still open (including the right hand-side interventions).
Hemorrhage after vaginal birthHemorrhage after cesarean delivery
Administer oxytocin
Perform uterine massage
Administer additional uterotonics (methergine, misoprostol, carboprost [Hemabate])
Bring 2 units of packed RBCs and 2 units of fresh frozen plasma (FFP) to point of care Transfuse based on the clinical condition Consider transfusing RBCs and FFP at a 1:1 ratio until clotting parameters are evaluated Obtain Stat clotting studies Start an additional intravenous line
Move the patient to the operating room
  • Inspect the broad ligament and posterior uterus
  • Check for retained placental tissue
Repair any tears
  • Place uterine devascularization sutures
  • Ligate the uterine artery
  • Ligate uterine vessels below the insertion of the fallopian tube
  • Perform dilation and curettage to rule out, or treat, retained placental tissue
  • Perform ultrasonography to assess the uterine cavity for retained placental tissue
Place uterine compression suture(s), such as a B-Lynch suture
Place an intrauterine balloonConsider bilateral ligation of the internal iliac artery
If indicated, call for additional specialists: second anesthesiologist, gyn surgeon, interventional radiologist, blood bank director
Selective embolization by interventional radiologyHysterectomy
Exploratory laparotomy—follow steps (along the right-hand side of this table) for treating hemorrhage after cesarean deliveryPelvic packing
Adapted from: California Maternal Quality Care Collaborative (

Placing an intrauterine balloon, such as the Bakri Postpartum Balloon (Cook Medical) or the BT-Cath (Utah Medical Products), is strongly recommended if these steps do not control bleeding.

In this Editorial, I review tips and tricks for using the Bakri balloon, building on my earlier OBG Management Editorial (February 2009), in which I outlined a basic approach to intrauterine balloon tamponade.4

TIP: Place the Bakri balloon early in the PPH treatment algorithm

For postpartum hemorrhage after vaginal delivery, typical initial steps include, as noted, fundal massage, administration of uterotonics, and curettage to remove retained products of conception. If these steps are ineffective, don’t wait: Immediately consider placing a Bakri balloon. Time is precious, and wasting time with less effective interventions results in excessive blood loss and consumption of clotting factors and increases the risk of a coagulopathy.

I’ve found that clinicians often spend too much time trying to determine whether postpartum bleeding originates in the uterus or from a cervical or vaginal laceration. But heavy bleeding can obscure anatomic structures, making it difficult to identify the site of bleeding with precision. Fruitlessly perseverating to differentiate uterine, cervical, and upper vaginal sources of bleeding can waste valuable time and lead to unnecessary blood loss.

By placing a Bakri balloon and inflating it early in the PPH treatment algorithm, you will significantly reduce uterine bleeding. You will also be able to assess the cervix and upper vagina more effectively for lacerations.

My recommendation. Place the Bakri balloon as soon as it is apparent that bleeding is so heavy that you are going to have difficulty assessing the cervix and upper vagina for lacerations. Note that this stands in contrast to the usual recommendation that you assess the cervix and vagina for lacerations before you place the Bakri balloon.

TIP: Have 3 clinicians place the balloon

Teamwork is a key to success here: The Bakri balloon is most quickly and elegantly inserted and inflated when three clinicians team up, as follows:

Clinician#1 scans the uterus, assessing for retained products of conception and providing real-time imaging as the balloon is placed and inflated. This team member provides feedback to the others about correct placement and filling of the balloon.


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